Provider Demographics
NPI:1215940440
Name:GODBERSEN, SCOTT THEODOR (DC)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:THEODOR
Last Name:GODBERSEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 WALDO HALTER MEM DR
Mailing Address - Street 2:PO BOX 355
Mailing Address - City:NEOSHO
Mailing Address - State:MO
Mailing Address - Zip Code:64850-2034
Mailing Address - Country:US
Mailing Address - Phone:417-455-1025
Mailing Address - Fax:417-455-2273
Practice Address - Street 1:1400 WALDO HALTER MEM DR
Practice Address - Street 2:
Practice Address - City:NEOSHO
Practice Address - State:MO
Practice Address - Zip Code:64850-2034
Practice Address - Country:US
Practice Address - Phone:417-455-1025
Practice Address - Fax:417-455-2273
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4833111N00000X
OK3847111N00000X
MO2008015775111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor